Journal of Orthodontics, Vol.

30, 2003, 171–174

FEATURES
SECTION
Current Products and Practice
Nickel allergy and orthodontics
G. Rahilly
Leeds Dental Institute, Leeds, UK

N. Price
Mayday Hospital, Surrey, UK

Abstract
Index words:
Delayed hypersensitivity,
nickel allergy, nickel-
titanium, nickel-free
Nickel is the most common metal to cause contact dermatitis in orthodontics. Nickel-containing
metal alloys, such as nickel-titanium and stainless steel, are widely used in orthodontic appli-
ances. Nickel-titanium alloys may have nickel content in excess of 50 per cent and can thus
potentially release enough nickel in the oral environment to elicit manifestations of an allergic
reaction. Stainless steel has a lower nickel content (8 per cent). However, because the nickel is
bound in a crystal lattice it is not available to react. Stainless steel orthodontic components are
therefore very unlikely to cause nickel hypersensitivity. This article discusses the diagnosis of
nickel allergy in orthodontics and describes alternative products that are nickel free or have a
very low nickel content, which would be appropriate to use in patients diagnosed with a nickel
allergy.

Introduction Occurrence of nickel allergy

Dermatitis due to contact with nickel was first reported
at the end of the nineteenth century among workers in
the nickel plating industry and was recognized as an
allergic response in 1925. This article discusses nickel
allergy in orthodontics. After briefly discussing the
biology of the reaction, we will explain the signs, symp-
toms and diagnosis of the condition. We will then dis-
cuss orthodontic appliance treatment options for patients
with nickel allergy.
Biology of the reaction
An allergic response is one in which certain components
of the immune system react excessively to a foreign
substance. Nickel elicits contact dermatitis, which is a
Type IV delayed hypersensitivity immune response.1
This process has two interrelated, distinct phases. A
sensitization phase occurs from the moment the allergen
enters the body, is recognized and a response occurs.
The elicitation phase occurs after re-exposure to the
allergen to the appearance of the full clinical reaction.
There may have been no symptoms at the initial expos-
ure, but subsequent exposure leads to a more visible
reaction.
Address for correspondence: Gerry Rahilly, Orthodontic Department, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, UK.
Email: gerardrahilly@hotmail.com
Within orthodontics, nickel is one of the most com-
monly used metals, as it is a component of the super
elastic and shape memory wires, and is included in stain-
less steel and other alloys. It has been shown that the
level of nickel in saliva and serum increases significantly
after the insertion of fixed orthodontic appliances.2
Nickel is the most common metal to cause contact
dermatitis in orthodontics, with more cases of allergic
reactions than all the other metals combined.3 Kerosuo
et al. found the prevalence of nickel allergy in Finnish
adolescents to be 30 per cent in girls and 3 per cent in
boys. This is thought to be due to ear piercing being a
major cause of sensitization to nickel, as the prevalence
in subjects with pierced ears was 31 per cent and those
without pierced ears 2 per cent.4 Once hypersensitivity
has been established, all oral mucosal surfaces can be
involved. Sensitizing patients to nickel through routine
orthodontic treatment with fixed appliances has been a
concern.5 It has been suggested that a threshold concen-
tration of approximately 30 ppm of nickel may be suffi-
cient to elicit a cytotoxic response.6 However, it has been
stated that oral antigenic contacts in non-sensitized
individuals may induce tolerance to nickel, rather than
sensitization.7 Nickel sensitization is believed to be
 172 G. Rahilly and N. Price
increased by mechanical irritation, skin maceration, or
oral mucosal injury, all of which may occur in ortho-
dontic treatment. Environmental temperatures and
duration of exposure may also be factors. The lesions of
contact stomatitis may be variable and may be barely
visible. Itching is not a common feature of contact
stomatitis (see Table 1)8 and extra-oral reactions are
more common than intra-oral reactions.
Diagnosis of nickel allergy
It is important to make a correct diagnosis of nickel
allergy, symptoms of which may occur either within or
remote to the oral environment. The following patient
history would suggest a diagnosis of nickel allergy:
• previous allergic response after wearing earrings or a
metal watchstrap;
• appearance of allergy symptoms shortly after the ini-
tial insertion of orthodontic components containing
nickel;
• confined extra-oral rash adjacent to headgear studs.
A dermatologist should confirm the diagnosis by patch
testing using 5 per cent nickel sulphate in petroleum
jelly.
Lesions due to other causes should be eliminated:
• candidiasis;
• herpetic stomatitis;
• ulcers due to mechanical irritation;
• allergies to other materials such as acrylic.
All adverse reactions to any orthodontic material should
be reported on an ‘Adverse Reaction to Dental Materials’
reporting form obtainable from Adverse Reaction
Reporting Project, Centre for Biomaterials and Tissue
Engineering, Department of Restorative Dentistry,
University of Sheffield, Sheffield S10 2TA, UK.
Table 1 Signs and symptoms of nickel allergy
Intra-oral Extra-oral
Stomatitis from mild to severe erythema Generalized urticaria
Papula peri-oral rash Widespread eczema
Loss of taste or metallic taste Flare-up of allergic
Numbness dermatitis
Burning sensation Exacerbation of
Soreness at side of the tongue pre-existing eczema
Angular cheilitis
Severe gingivitis in the absence of plaque
Features Section JO March 2003
Alternative materials for nickel allergy
patients
The potential for orthodontic metals to cause allergic
reactions is related to the pattern and mode of corrosion,
with subsequent release of metal ions, such as nickel,
into the oral cavity. This is dependent not only on the
composition of the metal, but also the temperature, pH
of the environment, and wear of the wire due to friction
from sliding mechanics, abrasion, presence of solder,
and strain of the wire.9 Stainless steel contains 8 per cent
nickel, whilst nickel-titanium wires may contain in
excess of 50 per cent.
Archwires
Stainless steel. The majority of investigations have
found that nickel sensitive patients are able to tolerate
stainless steel without any noticeable reaction and this is
thought to be due to the crystal lattice of the alloys
binding the nickel, which is then not free to react.10 The
only publications to report an allergic response to stain-
less steel wire are those where the stainless steel was used
for intermaxillary or internal fixation, had increased
nickel content and were not tested for corrosion.11,12
Most research concludes that stainless steel is a safe
material to use for all intra-oral orthodontic com-
ponents for nickel sensitive patients. Reduced nickel
content stainless steel is also available, but appears to be
unnecessary.
Nickel-titanium. Flexible nickel-titanium wires release
increased amounts of nickel and are thought to induce
nickel sensitivity: there may be up to 20 per cent conver-
sion rate.9 These high nickel content wires should be
avoided in nickel sensitive patients. Alternatives include
twistflex stainless steel, fibre-reinforced composite arch-
wires. Wires such as TMA, pure titanium, and gold-
plated wires may also be used without risk. Altered
nickel-titanium archwires also exist and include plastic/
resin-coated nickel-titanium archwires.13 Ion-implanted
nickel-titanium archwires have their surface bombarded
with nitrogen ions, which forms an amorphous surface
layer, conferring corrosion resistance and displacing
nickel atoms. Manufacturers claim that these altered
nickel-titanium archwires exhibit less corrosion than
stainless steel or non-coated nickel-titanium wires,
which results in a reduction of the release of nickel and
decreases the risk of an allergic response (see Table 2).
 JO March 2003 Features Section Current Products and Practice 173

Table 2 Nickel-free and nickel-‘lite’ wires and brackets

Company Nickel-free products

Wires Brackets

RMO Europe Bendalloy TMA wire Ceramic: Signature 3, Luxi 2 with gold slot
www.rmortho.com
The Orthodontic Company Resolve TMA wire Ion-implanted stanless steel: Platina
www.tocdental.com Bioforce wire with ionguard Ceramic with glass slot: Mystique
Epoxy coated wires Plastic: Oyster ligature free
3M Unitek Beta III Titanium Ceramic: Transcend, Clarity with stainless steel slot
www.3M.com/Unitek 24 carat gold-plated brackets
Forestadent TMA wire Ceramic with gold slot: Aspire
www.forestadent.com Flat Line acrylic coated wire Plastic: Brilliant
Titanium coated archwire
American Orthodontics Beta Titanium wire White gold  60% paladium: Virage
www.americanortho.com Polycarbonate 20/40
Reinforced polycarbonate: Silkon
Urethane: Classic
TP Orthodontics Timmolium (TMA) Nickel ‘free’ stainless steel: Avid
www.tportho.com Ceramic: MXI
Cobalt chrome: Nu edge
Ormco/A Company TMA Ceramic: Inspire
www.ormco.com Gold: Ortho 2
Titanium brackets
The Dental Directory Betaforce beta titanium Composite with metal slot: Avalon
www.dental-directory.co.uk
HSR Primo Biosteel (0.2% Ni) Siliaceous copolymer—Natura
www.hsrprimo.co.uk
Ortho-care Gold-plated wires Polycarbonate: Polar, Polar plus with gold slot
www.orthocare.co.uk Beta titanium wire Ceramic: Desire with gold slot
Precision Orthodontics Nickel-lite: Cobalt chromium alloy Composite with gold slot: Envision
www.orthoorganizer.co.uk CNA beta titanium Ceramic: Illusion, Contour
Gold-plated wires Nickel-lite: Cobalt chromium alloy
Resin coated wires Gold-plated brackets

Brackets appliances range from an increase of 30 per cent for

Stainless steel brackets again have low nickel content
(6 per cent) and are considered safe. However, nickel-
free alternative brackets to stainless steel include:
• ceramic brackets produced using polycrystalline
alumina, single-crystal sapphire, and zirconia;
• polycarbonate brackets that are produced from plastic
polymers;
• titanium brackets;
• gold-plated brackets.
Manufacturers are becoming more aware of the concern
of nickel allergy and many are producing ‘nickel-lite’
stainless steel versions (see Table 2). The cost implica-
tions of treating a nickel sensitive patient with fixed
‘nickel-lite’ brackets and archwires, to in excess of three
times the average cost of particular aesthetic brackets
and archwires. Extra-oral metal components, including
metal studs in headgear, are of greatest concern due to
greater sensitivity of the skin. Plastic-coated headgear
studs are available and may be a better alternative to
simply wrapping a bandage around the metal com-
ponent (see Table 3).
Conclusion
The craze for body piercing in younger age groups may
mean that an increased number of our patients may have
been sensitized to nickel by the time they reach our door.
 174 G. Rahilly and N. Price Features Section JO March 2003

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4. Kerosuo H, Kullaa A, Kerosuo E, Kanerva L, Hensten-
TP Orthodontics Plastic-coated headgear
Pettersen A. Nickel allergy in adolescents in relation to ortho-
www.tporto.com
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Masel TMA expansion screw Orthop 1996; 109: 148–54.
www.maselortho.com
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Sheffield Orthodontic Nickel-‘free’ ss wire for orthodontic patient. Am J Orthod Dentofac Orthop 1993; 103:
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